GRADUATE NON-DEGREE DATA FORM
Non-refundable initial enrollment fee of $10 must be
submitted with this form. Official undergraduate academic
transcripts are also required.
Jefferson College of Graduate Studies
Semester of intended
enrollment at TJU:
1020 Locust Street, M-60
Philadelphia, PA 19107-6799
Phone: (215) 503-4400
Fax: (215) 503-9920
E-Mail: jcgs-info@jefferson.edu
Web Address: www.jefferson.edu/jcgs
EDUCATIONAL OBJECTIVE:
Intend to Matriculate in:
Program
Professional Enhancement
Non-Degree Enrollment Only
Fall (Sep) _____
Spring (Jan) _____
Summer (Jun) _____
Name (Last, First, Middle initial)
Male
Female
Other Last, Family, or Surname that may appear on supporting documents:
Social Security #
Date of Birth (mo/da/yr)
Mailing Address (Street)
City
State
Zip
Phone Number w/Area Code
Permanent Legal Address (Street)
City
State
Zip
Phone Number w/Area Code
Employer (If TJU, list Department)
Work Phone Number
E-Mail Address
Citizenship (Country)
Visa Type (If not US citizen)
Response to this question is optional and is requested by the College in order to comply with statistical reporting to educational and
regulatory agencies and with its responsibilities under federal and state laws dealing with affirmative action and equal opportunity:
American Indian or Alaskan Native
Asian - American (Pacific Islander, Philippines, Guam)
Previous Colleges Attended:
Campus/Location
Asian
African-American
Attendance
From
To
Caucasian
Hispanic
Field of
Concentration
Other
Degree
Granted or Expected
Test Scores, if available (i.e., GRE, MAT, MCAT) Please indicate month and year that test was taken.
__________________________________________________________________________________________________________________________________________
I certify that the information on this form is accurate.
Signature
Date